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Background Significant disparity often exists between the findings of preoperative imagings and exploratory laparotomy Unnecessary laparotomy would increase patient’s morbidity both physically and psychologically

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1970s & 1980s Reports from 1970s & 1980s showed the role of laparoscopy in detecting occult metastases, allowing biopsy and avoiding unnecessary laparotomy close to 30 % in Ca pancreas. But no satisfactory imagings were available during that period of time and a lot of advanced cases were included in their studies Cushieri A et al, Gut 1978 Ishida H et al, Gastrointest Endosc 1983

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Obvious carcinomatosis on laparoscopy and it should not be missed on pre-op. CT

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Laparoscopic USG AdvantagesDisadvantages Identify invisible lesionsHighly operator dependent Better assessment of tumor vessel relationships Steep learning curve Help for better localization of guided biopsy View limited by the port position Restore part of the lost of tactile feedback Obscured in case of adhesions by previous surgery Increase the yield of diagnostic laparoscopy

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Resectability “ Resectability” would also vary according to different practice and the type of R resection of the study. The exact pathology and the clearance of tumour are not often mentioned in the those studies evaluating the usefulness of laparoscopy R 0 - gross and microscopic clear R 1 - gross clear by microscopic positive margin R 2 - both gross and microscopic margin involved Pisters PWT et al, Br J Surg 2001

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Cost-Benefit Consideration Routine diagnostic laparoscopy would need to be seven times cheaper than laparotomy to be justifiable from a cost-effective standpoint However diagnostic laparoscopy costs half as much as diagnostic laparotomy, and therefore routine diagnostic laparoscopy could be recommended It is not cost effective to use laparoscopy as an alternative to high-quality in a patient who is referred with marginal- quality CT that demonstrate a “resectable” pancreatic tumour Friess H et al J, Am Coll Surg 1998 Pisters PWT et al, Br J Surg 2001

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Routine vs Selective Policy Routine diagnostic laparoscopy should not be considered in obviously metastatic disease It should not be used to replace high quality CT scan In view of the cost consideration, indication would depend on how frequent will unnecessary laparotomy be spared. Potter MW et al, Surg Oncol 2000

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Conclusion Diagnostic Laparoscopy for patients with Pancreatic Tumor optimizes patient selection for tumour resection with curative intent Selective use of Laparoscopy after reviewing the Pre Op Imagings can avoid unnecessary laparotomy It is particular pronounced when non-surgical palliation is available Ampulla tumor are almost always resectable